case report a novel technique for laparoscopic salvage of...

Case ReportA Novel Technique for Laparoscopic Salvage ofCAPD Catheter Malfunction and Migration: The Santosh-PGIHanging Loop Technique

Santosh Kumar,1 Shivanshu Singh,1 Aditya Prakash Sharma,1 and Manish Rathi2

1Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India2Department of Nephrology, Postgraduate Institute of Medical Education and Research,Chandigarh 160012, India

Correspondence should be addressed to Santosh Kumar; [email protected]

Received 30 December 2014; Revised 13 March 2015; Accepted 16 March 2015

Academic Editor: Kostas C. Siamopoulos

Copyright © 2015 Santosh Kumar et al.This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

CAPD catheter malfunction is a common problem. Obstruction due to wrapping by appendices epiploicae of sigmoid colon hasbeen rarely reported in literature.We report a case of CAPD catheter malfunction caused by catheter tip migration and obstructionby appendices epiploicae that was successfully managed by laparoscopic hanging loop technique. This case report highlightsthe ease with which epiplopexy can be performed and catheter tip migration can be prevented by this innovative laparoscopicprocedure.

1. Introduction

CAPD (Continuous Ambulatory Peritoneal Dialysis) is aprevalent mode of renal replacement therapy with nearly197,000 ESRD patients using it globally [1]. One of theimportant aspects of CAPD catheter is its adequate functiondefined as one that allows adequate inflow and/or outflowof dialysate solution [2]. CAPD catheter malfunction isone of the major causes for its discontinuation. Cathetermalfunction can result from its luminal occlusion due toomental or small bowel wrapping, malposition, or migrationof catheter. Obstruction due to appendices epiploicae ofthe sigmoid colon is a rarely reported etiology [3]. Laparo-scopic salvage of malfunctioning catheters helps in reducingpatient’s morbidity and need of intermediary hemodialysis.However, recurrent malfunction had motivated surgeons toinnovate newer methods of laparoscopic CAPD cathetersalvage. We report a case of CAPD catheter occlusion causedby wrapping of appendices epiploicae of sigmoid colon, arare cause. Laparoscopic “Santosh-PGI Hanging Loop Tech-nique,” an innovative concept withmultiple benefits, salvagedit.

2. Case Report

A 54-year-old gentleman having diabetes and hypertensionwas diagnosed as end-stage renal disease requiring renalreplacement therapy. He opted for CAPD. His serum cre-atinine was 7.9mg/dL. Straight Tenckhoff CAPD catheterinsertion was done by standard open technique. Patientwas discharged on postoperative day three. Two weeks afterinsertion, CAPD initiation was planned. However, there wasslow inflow and a trickling outflow. Diagnosis of CAPDcatheter malfunction was made. X-ray abdomen revealedmalposition of CAPD catheter (Figure 1(a)). It was lyingoutside the pelvis in left lateral abdomen. Initial managementwith laxatives, bowel enema, failed with no improvement indialysate flux. Repositioning of CAPDcatheter was attemptedunder fluoroscopic guidance but it was unsuccessful. Keep-ing a diagnosis of CAPD catheter malposition with sus-pected omental wrapping, decision was made for diagnosticlaparoscopy along with a salvage procedure as required.

Under general anesthesia, laparoscopy was performedwith the patient in supine position with Trendelenburg tilt.Three ports were placed including one 12mm camera and

Hindawi Publishing CorporationCase Reports in NephrologyVolume 2015, Article ID 684976, 4 pageshttp://dx.doi.org/10.1155/2015/684976

2 Case Reports in Nephrology

(a)

5mm12mm

12mmScarPeritoneal catheter

(b)

Figure 1: X-ray abdomen showing migrated CAPD catheter lying outside the pelvis (a). Illustration of laparoscopic port placement (b). Themiddle 12mm blue cross is the camera port while the corners 12mm and 5mm are the working ports.

(a)

CC

AESC

SM

(b)

CAPD catheter

Hanging prolene loopsHC

SC

(c)(d)

Figure 2: Laparoscopic view demonstrating wrapped-up CAPD catheter by appendices epiploicae of sigmoid colon (a). Dissection of thecatheter from epiploicae using harmonic shear device (b). CAPD catheter hanging freely over prolene loops that are fixed to the pelvicparietal peritoneum using hemostatic clips (c). Epiplopexy using hemostatic clips (d) (AE = appendices epiploicae; CC = CAPD catheter; SC= sigmoid colon; SM = sigmoid mesocolon; HC = hemostatic clips).

two working ports (Figure 1(b)). To our surprise, the catheterwas engulfed by appendices epiploicae of sigmoid colon(Figure 2). With the help of laparoscopic harmonic sheardevice, the catheter was completely dissected off from theappendices epiploicae. It was repositioned in the pelvis. Fur-ther, in an attempt to prevent recurrent CAPD catheter occlu-sion and migration, an innovative “Santosh-PGI Hanging

Loop Technique” was applied. In this, prolene 2-0 needlelesssuture was taken. Two knots were applied on it, one oneach side. This suture was then passed into peritoneal cavitythrough one of the ports. A loop was made around theCAPD catheter and was fixed to the pelvic peritoneum withhelp of hemostatic clips. Similarly, two more loops wereapplied. In this way, the CAPD catheter was hanged freely

Case Reports in Nephrology 3

underneath the pelvic peritoneum with the help of prolenesuture. To prevent appendices epiploicae from falling backon the catheter, they were fixed to the left lower abdominalparietal peritoneum using hemostatic clips. On table catheterpatency and position were confirmed. Postoperative periodwas uneventful. Low volume dialysis was started on 1stpostoperative day. Normal volume dialysis was resumed byday 9. At 6-month follow-up his catheter is functioning well.Repeat X-ray imaging revealed its pelvic position.

3. Discussion

From 1997 to 2008, the number of peritoneal dialysis patientsin developing countries increased by 24.9 patients permillionpopulation while in developed countries it increased by21.8 per million population [1]. CAPD catheter malfunc-tion is one of the major causes for discontinuation of thistherapeutic modality. Incidence ranges from 12 to 73% [4].Catheter malfunction accounts for 20% of patient transfersto hemodialysis [5]. Malfunction can result from occlusion ofcatheter by omental or small bowel wrapping with adhesions,fibrin clot, migration or malposition, and tunnel infections.Various series have reported omental wrapping and malposi-tion to be the most common cause of malfunction [2, 6, 7].Appendices epiploicae has been rarely reported as a causeof catheter occlusion [3]. CAPD catheter salvage insteadof removal helps in functional rescue, thereby prolongingcatheter life, decreasing patient morbidity, reducing financialburden, and allowing early institution of peritoneal dialysis,thereby decreasing dependence on intermediary hemodial-ysis [8]. Laparoscopic salvage of CAPD catheters has severalreported advantages [8]. Laparoscopy provides a direct visionof the pathology, helps in diagnosis of other intra-abdominalpathologies, has lower incidence of postsurgical adhesions,incision related complications, postprocedure pain, therebyresulting in early ambulation, shorter hospital stay withquicker return towork. It allows early institution of peritonealdialysis and better functional survival of catheter. Salvageprocedures include laparoscopic unwrapping of omentumwith omentectomy, omentopexy, [2] adhesiolysis, or laparo-scopic milking of occluded catheters [9]. Laparoscopicallysalvaged catheters have been shown to have reasonably goodperiod of catheter survival with a median of 163 days insome studies [7]. Initial success rates of as high as 100%have been reported [8] highlighting the usefulness of salvageprocedures.

Catheter tip migration contributes to a substantial pro-portion of catheter malfunction.Those not corrected by con-servative or stiff wire manipulation require surgical interven-tion. Laparoscopic salvage has definite advantages over opensurgical procedures. Laparoscopic preperitoneal placementand pelvic fixation using extracorporeal knotting have beenreported in an attempt to prevent catheter migration [10]. Wereport an innovative, easily performed technique of laparo-scopic rescue of CAPD cathetermalfunction due to wrappingby appendices epiploicae of sigmoid colon and catheter tipmigration. In this, we first unwrapped the catheter fromappendices epiploicae.The catheter was freely hanged under-neath the pelvic peritoneum over prolene suture loops that

were fixed to the peritoneum with hemostatic clips usinglaparoscopic clip applicator. The tip of the catheter was inthe pelvic cavity. This technique has several advantages.Suture fixation is easy with hemostatic clips. The catheterhangs freely in the loop thereby allowing easy removal orexchange in the future. No separate incisions are required forsubcutaneous suture fixation as it is done intraperitoneally.In order to prevent appendices from falling back on catheter,it was fixed to left lateral wall with hemostatic clips. Thistechnique highlights the simplicity with which the cathetermigration and occlusion can be prevented.

4. Conclusion

CAPD catheter malfunction is a common problem. Laparo-scopic salvage of such catheters decreases patient’s morbidity.The laparoscopic hanging loop technique with epiplopexyusing hemostatic clips helps in effectively preventing cathetertip migration out of pelvic cavity and rewrapping of catheterby appendices epiploicae.

Conflict of Interests

The authors report no conflict of interests.

References

[1] A. K. Jain, P. Blake, P. Cordy, and A. X. Garg, “Global trends inrates of peritoneal dialysis,” Journal of the American Society ofNephrology, vol. 23, no. 3, pp. 533–544, 2012.

[2] H. M. Zakaria, “Laparoscopic management of malfunctioningperitoneal dialysis catheters,”OmanMedical Journal, vol. 26, no.3, pp. 171–174, 2011.

[3] J. H. Crabtree and A. Fishman, “Laparoscopic epiplopexy ofthe greater omentum and epiploic appendices in the sal-vaging of dysfunctional peritoneal dialysis catheters,” SurgicalLaparoscopy, Endoscopy and Percutaneous Techniques, vol. 6, no.3, pp. 176–180, 1996.

[4] J. Bernardini, B. Piraino, J. L. Holley, J. R. Johnston, and R.Lutes, “A randomized trial of Staphylococcus aureus prophylaxisin peritoneal dialysis patients: mupirocin calcium ointment 2%applied to the exit site versus cyclic oral rifampin,” AmericanJournal of Kidney Diseases, vol. 27, no. 5, pp. 695–700, 1996.

[5] G. Ogunc, “Minilaparoscopic extraperitoneal tunneling withomentopexy: a new technique for CAPD catheter placement,”Peritoneal Dialysis International, vol. 25, no. 6, pp. 551–555,2005.

[6] G. Kazemzadeh, M.-H. S. Modaghegh, and A. Tavassoli, “Lap-aroscopic correction of peritoneal catheter dysfunction,” IndianJournal of Surgery, vol. 70, no. 5, pp. 227–230, 2008.

[7] S. Santarelli, M. Zeiler, R. Marinelli, T. Monteburini, A. Fed-erico, and E. Ceraudo, “Videolaparoscopy as rescue therapyand placement of peritoneal dialysis catheters: s thirty-two casesingle centre experience,” Nephrology Dialysis Transplantation,vol. 21, no. 5, pp. 1348–1354, 2006.

[8] G. Ogunc, “Malfunctioning peritoneal dialysis catheter andaccompanying surgical pathology repaired by laparoscopicsurgery,”PeritonealDialysis International, vol. 22, no. 4, pp. 454–462, 2002.

4 Case Reports in Nephrology

[9] C. Fourtounas, I. Maroulis, D. Karnabatidis, A. Hardalias, andJ. G. Vlachojannis, “Salvage of a totally occluded peritonealdialysis catheter by laparoscopic milking,” Seminars in Dialysis,vol. 26, no. 1, pp. E8–E10, 2013.

[10] M. E. Gunes, G. Uzum, O. Koc et al., “A modified method inlaparoscopic peritoneal catheter implantation: the combinationof preperitoneal tunneling and pelvic fixation,” ISRN Surgery,vol. 2013, Article ID 248126, 5 pages, 2013.

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